2005 Abstracts: Laparoscopic Transgastric Endoscopic Retrograde Cholangiopancreatography for Diagnosing and Managing Complex Problems in Bariatric Patients
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Laparoscopic Transgastric Endoscopic Retrograde Cholangiopancreatography for Diagnosing and Managing Complex Problems in Bariatric Patients
Susan B. Young, Nagan, Arregui, Davis Inc., Indianapolis, IN; Maurice Arregui, St. Vincent Hospital, Indianapolis Indiana, Indianapolis, IN
Introduction: Long Roux-en-y limbs in bariatric patients are a barrier to endoscopic retrograde cholangiopancreatography (ERCP). Laparoscopic transgastric ERCP(LTGERCP)has recently been described to manage biliary problems. We describe three cases of pancreas divisum and one of sphnicter of Oddi(SO) hypertension managed with LTGERCP.
Methods: Four bariatric patients with pancreatic or biliary pain, nausea, and vomiting were referred for ERCP. All had 100 cm Roux-en-y limbs. All had previous cholecystectomy. The LTGERCP begins with a gastrostomy to access the gastric remnant. A 12 mm port is placed into the stomach through which the side-viewing diagnostic endoscope is advanced. ERCP including SO manometry, diagnostic cannulations, and therapeutic procedures are performed. A gastrostomy tube is placed if a second ERCP or stent removal is anticipated. Results: July to November 2004 four women, mean age 46 years, had successful LTGERCP. Three had elevated liver function tests and two elevated lipase or amylase. Two had dilated common bile ducts. Three patients has SO manometry. One had a stricture of the SO preventing manometry. Cholangiogram and pancreaticogram of Wirsungs duct was obtained in all cases. Pancreaticogram through the minor papilla was attempted in three patients and complete in two. Endoscopic treatment in one patient was biliary sphnicterotomy and in two patients biliary and major pancreatic sphnicterotomy with stent. One patient had a stent placed and papillotomy of the minor papilla. Three patients demonstrated pancreas divisum, two of which had SO hypertension (>40 mmHg). One patient had only SO hypertension. There were no operative complications. Resolution of symptoms occurred with LTGERCP biliary sphnicterotomy in a patient with SO hypertension and pancreas divisum. Two patients with pancreas divisum have had open transduodenal sphnicteroplasty. The first had sphnicteroplasty of the minor papilla by us after a major papilla sphnicteroplasty by another surgeon, she has had improvement in symptoms. The second patient had a sphnicteroplasty of both major (biliary and pancreatic) and minor papilla with complete ressolution of symptoms. The patient with SO hypertension demonstrates only mild improvement and is scheduled for open transduodenal sphnicteroplasty. Conclusion: We successfully completed advanced diagnostic and therapeutic LTGERCP in bariatric patients with complex pancreatico-biliary problems.
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